|
Broadly speaking,
health insurance data are records of all enrollees in a program
(enrollment data) and a listing of the covered services provided
for which payment was requested and paid (claims data). The structure
of administrative data is similar for all major payers--Medicare,
Medicaid, and private insurance companies. This is because hospitals,
physicians, pharmacies, and other health care providers use the
same forms for everyone. Even though payment rules may vary depending
on the payer, the forms used to submit bills are the same.
Claims data
contain the information necessary for providers to get paid for
services rendered to beneficiaries and are submitted on one of
two forms; the Uniform Bill-92
(UB-92) or the Centers
for Medicare and Medicaid Services 1500 (CMS 1500).
The UB-92
is used for facility claims such as hospitals, hospices and hospital
outpatient departments. The primary billing components of this
form that describe the services rendered are the revenue
center codes, International
Classification of Diseases 9th Edition (ICD-9) diagnoses,
and ICD-9
procedure codes. Information about dollars include:
Claims do not generally reflect out
of pocket expenses.
The CMS 1500
is used for physicians, suppliers (such as pharmacies, durable
medical equipment suppliers) and other providers who are not considered
facilities by Medicare. The primary components of this form that
describe services rendered are Healthcare Common Procedure Coding
System (HCPCS) codes or Current Procedure Terminology (CPT) codes,
and ICD-9 diagnoses.
The basis
for payment varies from service to service and from claim type
to claim type. A good general rule is that the information needed
for paying bills will be of the highest quality, followed by information
that is audited. Click
here for a table illustrating the basis for payments for Medicare
services.
|